A third of serious case reviews judged 'inadequate'

Learning lessons from serious case reviews: year 2 is the second evaluation report of serious case reviews carried out and completed between 1 April 2008 and 31 March 2009. It follows on from Learning lessons, taking action: Ofsted's evaluations of series case reviews 1 April 2007 to 31 March 2008.

The findings show that several weaknesses in practice identified in the previous report remain across the various groups. Instances of weak management and lack of joint working within and across agencies remain in some areas. Other examples of weak practice include failure to focus on the needs of the child, insufficient staff expertise, not making adequate risk assessments, and poor identification of ethnic or social cultural issues.

Government guidance requires that where a child dies and abuse or neglect is known or suspected to be a factor, the Local Safeguarding Children Board (LSCB) must conduct a serious case review.

The 173 serious case reviews carried out and completed between 1 April 2008 and 31 March 2009, relate to 219 children and include 113 cases of child deaths as a result of an incident. Of the 219 children identified, 68% were known to social care services at the time of the incident.

Ofsted also found that some local areas are learning lessons with 23% of reviews being judged good and 43% adequate.

The report, published yesterday, found evidence to suggest that reviews are being carried out in a greater number of cases and by a larger number of LSCBs. These reviews are being carried out more quickly and with greater levels of independence, and the backlog of historic cases is largely now addressed. In addition there is evidence that LSCBs are co-operating more readily where a review spans more than one area.

Christine Gilbert, Her Majesty's Chief Inspector, said: "There are encouraging signs of improvement identified in this report. Agencies and local authorities are looking more rigorously at their processes and practices to learn lessons from tragic incidents. Learning these lessons will help protect more children from harm.

"However, much more work needs to be done to address the remaining weaknesses and to ensure that lessons lead to improved outcomes for children and young people. It is of great concern that over a third of reviews are still judged inadequate.

"We all have a duty to protect children from harm. It is crucial that those involved in child protection use the serious case review process to deliver change and improvement," Ms Gilbert concluded.